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Traumatic Injuries of the Distal Radioulnar Joint
Orthop Clin N Am 38 (2007) 289–297
Traumatic Injuries of the Distal Radioulnar Joint Jonathan S. Mulford, BMEDSc, MBBS, FRACSa, Terry S. Axelrod, MD, MSc, FRCS(C)a,b,* a
Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, University of Toronto, MG301, 2075 Bayview Avenue, Toronto, Ontario, Canada M4N 3M5 b Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Ontario, Canada M4N 3M5
Traumatic injuries of the distal radioulnar joint (DRUJ) give rise to wrist pathologies that require special consideration for management. There may be substantial ongoing disability arising from failure to recognize, treat, and rehabilitate individuals with injuries to the DRUJ. These may occur as isolated injuries without associated fractures, but occur more commonly with fractures of the radius. These challenging DRUJ injuries may be simple or complex (irreducible or severe instability). They also may be acute or become a chronic problem. An adequate knowledge of the stabilizers of the DRUJ is essential in understanding treatment options. Traumatic instability of the DRUJ, its anatomy, and its stabilizing factors are reviewed, followed by an algorithm to guide selection of treatment options in complex cases. The anatomy and stabilizers of the distal radioulnar joint The DRUJ is stabilized by way of a complex arrangement involving bony congruence and soft tissue constraints. The gross anatomy of the DRUJ is illustrated in Figs. 1 and 2. The DRUJ consists of a complex articulation between the bony elements of the
* Corresponding author. Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, University of Toronto, MG301, 2075 Bayview Avenue, Toronto, Ontario, Canada M4N 3M5. E-mail address: [email protected] (T.S. Axelrod).
ulnar head and the sigmoid notch of the distal radius. This articulation is shallow and relies on soft tissue stabilizers to maintain joint integrity. The triangular fibrocartilage complex (TFCC) is the most essential soft tissue stabilizer of the DRUJ. Bony stabilizers The ulnar head articulates with the sigmoid notch of the distal radius. The congruence between the two bones provides some stability to the DRUJ [1,2]. The sigmoid notch and the ulnar head have different arcs of curvature. The sigmoid notch arc of curvature is larger and so with forearm rotation, translation also occurs at the DRUJ. There is volar translation of the ulnar head with supination and dorsal translation with pronation. Soft tissue stabilizers There are primary and secondary soft tissue stabilizers of the DRUJ. The degree of instability may occur in definable stages, depending on the magnitude of injury to the soft tissue stabilizers of this joint [3]. Primary stabilizer The TFCC is an essential stabilizer of the DRUJ. It encompasses the sheath of the extensor carpi ulnaris tendon, the ulnocarpal ligaments, the radioulnar ligaments, and the triangular fibrocartilage. The dorsal and volar radioulnar ligaments are the major stabilizers [2,4,5]. The foveal insertion of the TFCC is the most important [6] attachment for stability.
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Typically, these injuries are traumatic dislocations of the distal ulnar, either dorsal or volar. Soft tissue injuries, including TFCC injuries, causing instability are included in this group. Volar
Fig. 1. Bony anatomy of the DRUJ. Note the sigmoid notch of the distal radius and the conical shape of the ulnar head.
Secondary stabilizers There are static and dynamic stabilizers of the DRUJ [2,7,8]. Static secondary stabilizers include the joint capsule and the interosseous membrane. Dynamic stabilizers include the extensor carpi ulnaris (ECU) and pronator quadratus.
Isolated distal radioulnar joint dislocation Isolated DRUJ dislocation involves trauma to the joint that is not associated with a fracture of the radius. It is neither a Galeazzi injury nor one with injury to the distal radius articular segments of the DRUJ.
Isolated volar dislocation of the DRUJ is uncommon. Typically, the mechanism of injury is the classic fall on the outstretched arm, usually with a rotational supination force to the impact. The physical examination is notable for the absence of the typical dorsal prominence of the ulnar head and the lack of forearm rotation. Radiographs illustrate an overlap of the distal ulnar to the distal radius on the posteroanterior (PA) film (Fig. 3). A review of the literature identified 23 cases of isolated volar DRUJ dislocation since 1960 [9]. Fifteen of the 23 cases were misdiagnosed initially. If the injury was diagnosed acutely, most (9 of 11) were reduced successfully by closed reduction. Only 1 out of 12 chronic cases was treated successfully with closed reduction. Reasons to account for the irreducible dislocations included block from the TFCC [10] or the pronator quadratus [11], interposition of the extensor tendons and extensor retinaculum [12], and impaction ulnar head fracture resulting in locking on the sigmoid notch [9]. Only one chronic dislocation was treated successfully with closed reduction [13]. Most required salvage surgery (five Darrach procedures [14], three Suave Kapanji procedures [12], and one hemiresection of the ulnar head [13]). It has been suggested that a forceful closed reduction should be attempted in a chronic dislocation. This may lead to fracture if there is locked dislocation. The authors advocate the use of a CT scan of the DRUJ to exclude any impacted fracture before any attempt at a closed reduction (Fig. 4). If there is a locked dislocation with bony impaction, the authors advise open reduction of the dislocation. Dorsal
Fig. 2. Soft tissue anatomy of the DRUJ, specifically the TFCC. Note the ulnar sheath of the extensor carpi ulnaris tendon, the ulnocarpal and radiocarpal ligaments, and the triangular fibrocartilage itself. (Courtesy of Amit Gupta, MD, and Makoto Tamai, MD, Louisville, KY.)
Dorsal dislocation is more common than volar dislocation of the DRUJ. Dorsal dislocations also occur with a similar mechanism to the volar dislocation as described above. The rotational moment usually is in pronation. The physical examination usually indicates excessive prominence of the ulnar head and the similar lack of forearm rotation.
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Fig. 3. PA (A) and lateral (B) radiographs of an acute DRUJ dislocation. There is overlap of the ulnar head with the distal radius, whereas a normal joint space should be seen. Note the volar position of the ulnar head on the lateral projection.
Radiographs show findings similar to those for volar dislocations, except that the ulnar head is displaced in the dorsal direction on the lateral projection. Usually, closed reduction is successful using digital pressure over the ulnar head and supination. The dislocation may be complicated by irreducibility or ongoing instability (complex dislocation). In these cases, the patient can be managed as described below for patients with combined injuries. Underlying factors that may block reduction are similar to those described above for isolated volar dislocation.
Fig. 4. CT axial cut of a locked volar dislocation of the DRUJ, comparison with the normal contralateral wrist is provided.
Combined injury with fractured radius Combined injuries include Galeazzi injuries or distal radial fractures with DRUJ injury. A Galeazzi injury is characterized by a displaced distal radius fracture with a dislocation of the DRUJ. Usually, the diagnosis is straightforward, owing to the often dramatic appearance of the disruption of the DRUJ with the displaced radius (Fig. 5). Typically, the dislocation is dorsal, but it can occur in any direction depending on the displacement of the distal segment of the radius. Frequently, fractures of the distal radius associated with displacement result in an injury to the ulnar side of the wrist. This may involve the ulnar shaft, neck, or head fracture. More typically, there is some disruption of the soft tissue supporting structures of the DRUJ, resulting in varying degrees of instability, subluxation, or dislocation. Traditionally, DRUJ instability was believed to occur rarely in combined injuries [15–17]. Sixty percent [15] of patients with a distal radius fracture have an ulnar styloid fracture, but most do not have instability. Recent outcome reviews found that ulnar-sided wrist problems occur in 3% to 37% of distal radial fractures [18–23] and often are due to DRUJ instability. A large-sized ulnar styloid fragment (type II fractures [19]) with displacement is more likely to result in DRUJ instability [19,21,24]. Many patients with a distal radius fracture have accompanying
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Fig. 5. Galeazzi fracture-dislocation of the wrist. Preoperative initial radiographs reveal the gross displacement of the radius fracture with the dislocation of the distal radioulnar joint. Preoperative initial lateral radiograph with dorsal dislocation of the ulnar head. Postoperative radiographs indicate anatomic reduction of the radius and the DRUJ.
TFCC tears; however, they are likely to remain asymptomatic if the joint is stable [25]. Reduced outcome scores have been well documented in radial fractures complicated by instability [23,26–28]. If the clinician has an awareness of the possibility of these associated DRUJ injuries, clinical and radiological testing can be directed toward recognizing and effectively treating these injuries and improving their outcome. The instability of the DRUJ in association with radial fractures can be addressed acutely or chronically. Acute injury Early treatment of acute injury gives rise to better results than does surgical management of chronic instability [18,21,29]. An algorithm is described for the management of acute DRUJ instability (Fig. 6) associated with radial fracture. This is based on a series of difficult cases [30] that was managed by the senior author and a review of the literature. The risk for DRUJ instability can be assessed according to the mechanism of injury (eg, highenergy trauma with rotational component) and initial radiographs. Radiological indicators of potential DRUJ instability include (1) an ulnar styloid fracture involving the base with more than 2 mm displacement [18,21,31], (2) an irreducible dislocation of the DRUJ, (3) fractures
involving the sigmoid notch of the radius, (4) a wide displacement of the DRUJ, and (5) radial shortening. In the operating room, the initial goal is anatomic reduction of the radius. Following reduction of the radius, the DRUJ can be assessed for stability in different positions of forearm rotation using the piano key sign [32]. The presence of this sign can be subtle and comparison to the contralateral DRUJ may be required. If the joint is stable, no further operative intervention is required, whereas any ongoing instability must be addressed. If instability is detected, the quality of the radius fracture reduction should be reassessed to ensure restoration of the anatomy. If the reduction in nonanatomic, it must be revised, and the status of the DRUJ must be reevaluated. Instability that occurs in some positions of forearm rotation may be considered for casting in a position of stability. Typically, dorsal dislocations are stable in supination, whereas the unusual volar dislocations are stable in pronation. The limb can be immobilized in the stable position with an above-elbow splint or brace for a period of 4 to 6 weeks until the soft tissue structures stabilize. Complex instability occurs when the DRUJ is irreducible or unstable in all positions. Fig. 7 illustrates the typical pathology noted with a complex injury of the DRUJ.
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ACUTE DRUJ INJURY
Anatomic Reduction of Radius then Assess DRUJ Stability
Complex DRUJ Injury
Stable DRUJ
Partially Stable DRUJ
No Immobilization Required
Hold in Position of Stability for 4-6 weeks
Unstable in All Directions
Irreducible
Open Reduction Required Ulnar Styloid Fracture?
Large Displaced Ulnar Styloid
No Ulnar Styloid Fracture
Open Reduction and Internal Fixation
Repair of TFCC with transfixion pinning of reduced DRUJ for 4-6 weeks
Fig. 6. Algorithm for the management of acute injuries of the DRUJ.
Irreducible distal radioulnar joint An irreducible DRUJ has a block to reduction. This is characterized by soft tissue, or less often, bone interposition within the joint. Complete joint reduction may be blocked by (1) the ulnar head incarceration through a rent in the capsule of the DRUJ, (2) tendons, such as the ECU or flexor carpi ulnaris, (3) a bone fragment from the ulnar or sigmoid notch of the radius. If the joint cannot be reduced, an arthrotomy is performed, and the offending obstacle to reduction is removed. The approach is dictated by
the pattern of displacement of the dislocation. Often, the simplest approach is to expose the DRUJ by way of the ECU subsheath. This involves mobilizing the ECU with a dorsal ulnar linear incision. The skin incision is made, and the dorsal sensory branch of the ulnar nerve is identified and protected. The ECU tendon is retracted, and the subsheath is incised longitudinally. This brings the surgeon directly onto the ulnar styloid. This exposure allows reconstruction of the TFCC and the ulnar styloid, should it be indicated (Fig. 8). If the ulnar head is trapped
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Fig. 7. Typical pathology associated with a complex dislocation, showing disruption of the distal radioulnar joint ligaments, a portion of the interosseous membrane, the floor of the ECU tendon sheath, and an avulsion fracture of the ulnar styloid process. (From Cheng SL, Axelrod TS. Management of complex dislocations of the distal radioulnar joint. Clin Orthop Relat Res 1997;341:186; with permission.)
within the volar capsule, a volar exposured between the long flexors and the ulnar neurovascular structuresdallows adequate visualization of the joint and capsule to perform an open reduction. Reducible but unstable distal radioulnar joint Usually, instability in all positions is associated with a large, displaced ulnar styloid fracture and is managed by way of internal fixation. Often, this also addresses the stability of the DRUJ because the TFCC is attached to the fragment (see Fig. 8) [24,33]. If the ulnar is not fractured, the TFCC is likely to have a peripheral tear. Closed treatment of an unstable DRUJ results in a high incidence of recurrent subluxation or dislocation and residual pain [34]. Surgical options in this situation include reduction of the DRUJ with ulno-radial transfixion pins [35–38], repair of the TFCC (open [18], mini-open [39], or arthroscopically [40–46]), or an external fixateur of the radius with an outrigger to the ulnar [47]. There are few studies to guide which of these techniques has the best outcome,
Fig. 8. The technique of tension band wire fixation of the ulnar styloid process. A 1.6-mm K-wire is used to fix the styloid process to the ulnar shaft, and a 22-gauge wire is passed around the ulnar collateral ligament complex and the ulnar styloid. It is then passed through a drill hole in the ulnar shaft and tied in a figure-of-eight fashion. The inset shows completed fixation with the Kwire bent over and cut short to prevent irritation of the adjacent soft tissues. (From Cheng SL, Axelrod TS. Management of complex dislocations of the distal radioulnar joint. Clin Orthop Relat Res 1997;341:187; with permission.)
with each technique having reported success in small case series. The authors favor mini-open repair of the TFCC with short-term transfixion pins in supination. The suture repair of the TFCC with a grossly unstable DRUJ dislocation is not strong enough with current techniques to hold the reduction until healing is complete. Transfixion pinning gives initial protection to the repair.
Chronic instability following fracture of the distal radius Chronic instability of the DRUJ can undergo a trial of nonoperative management, including bracing [48]. These cases can have other causes of ulnar-sided wrist pain that may mimic or coexist with DRUJ instability. These include DRUJ arthritis, ECU tendonitis, ulnar abutment, central TFCC tear, and ulnar carpal instability. These
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Finally, if repair or reconstructive procedures are unsuccessful or not indicated (eg, DRUJ degenerative changes), salvage surgery can be considered. These include Darrach [62], SauveKapandji [63], ulnar head arthroplasty, and hemiresection [64] procedures.
CHRONIC DRUJ INJURY
Degenerative Change of DRUJ?
YES
Summary
NO
Salvage procedure: eg Darrach, Sauve-Kapandji, or hemiresection.
YES Osteotomy (radius or ulna) or osteoplasty + soft tissue stabilization
295
Any Bony Deformity?
A knowledge and awareness of the stabilizing factors of the DRUJ are important in managing DRUJ instability. An algorithm for management options presented here allows the clinician to make sound clinical decisions for the management of complex instability of the DRUJ in trauma.
NO
References Soft tissue stabilizing procedure
Fig. 9. Algorithm for the management of chronic posttrauma instability of the DRUJ.
conditions should be considered in the clinical and radiological assessment. If nonoperative treatment is unsuccessful, the goals of surgical treatment are to restore stability and obtain a functional painless arc of forearm rotation. To achieve this, one must identify any bony deformity or ligament injuries. An algorithm is described for the management of chronic DRUJ instability (Fig. 9). Bony abnormalities causing instability include radial or ulnar malunion or loss of the curve of the radius on the sigmoid notch. Osteotomies of the radius [49,50] or ulnar [51] or an osteoplasty of the sigmoid notch [52] can improve stability in these situations. Once the bony anatomy is restored, the soft tissue can be addressed. Late repair of the TFCC complex can be considered [53], although attenuated tissues may preclude primary repair. Reconstructive procedures can be used if there is no DRUJ arthritis and the sigmoid notch is competent. Possible reconstructions include indirect radioulnar link by way of an ulnar carpal sling or tenodesis [54–57] or reconstruction of the distal radioulnar ligaments [58,59]. These techniques were reported to give improvement in small series. Cadaveric studies, however, showed that tenodesis procedures do not restore DRUJ mechanics [60], whereas intraarticular reconstructive procedures restore stability without limitations on forearm rotation [61].
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Traumatic Injuries of the Distal Radioulnar Joint Jonathan S. Mulford, BMEDSc, MBBS, FRACSa, Terry S. Axelrod, MD, MSc, FRCS(C)a,b,* a
Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, University of Toronto, MG301, 2075 Bayview Avenue, Toronto, Ontario, Canada M4N 3M5 b Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Ontario, Canada M4N 3M5
Traumatic injuries of the distal radioulnar joint (DRUJ) give rise to wrist pathologies that require special consideration for management. There may be substantial ongoing disability arising from failure to recognize, treat, and rehabilitate individuals with injuries to the DRUJ. These may occur as isolated injuries without associated fractures, but occur more commonly with fractures of the radius. These challenging DRUJ injuries may be simple or complex (irreducible or severe instability). They also may be acute or become a chronic problem. An adequate knowledge of the stabilizers of the DRUJ is essential in understanding treatment options. Traumatic instability of the DRUJ, its anatomy, and its stabilizing factors are reviewed, followed by an algorithm to guide selection of treatment options in complex cases. The anatomy and stabilizers of the distal radioulnar joint The DRUJ is stabilized by way of a complex arrangement involving bony congruence and soft tissue constraints. The gross anatomy of the DRUJ is illustrated in Figs. 1 and 2. The DRUJ consists of a complex articulation between the bony elements of the
* Corresponding author. Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, University of Toronto, MG301, 2075 Bayview Avenue, Toronto, Ontario, Canada M4N 3M5. E-mail address: [email protected] (T.S. Axelrod).
ulnar head and the sigmoid notch of the distal radius. This articulation is shallow and relies on soft tissue stabilizers to maintain joint integrity. The triangular fibrocartilage complex (TFCC) is the most essential soft tissue stabilizer of the DRUJ. Bony stabilizers The ulnar head articulates with the sigmoid notch of the distal radius. The congruence between the two bones provides some stability to the DRUJ [1,2]. The sigmoid notch and the ulnar head have different arcs of curvature. The sigmoid notch arc of curvature is larger and so with forearm rotation, translation also occurs at the DRUJ. There is volar translation of the ulnar head with supination and dorsal translation with pronation. Soft tissue stabilizers There are primary and secondary soft tissue stabilizers of the DRUJ. The degree of instability may occur in definable stages, depending on the magnitude of injury to the soft tissue stabilizers of this joint [3]. Primary stabilizer The TFCC is an essential stabilizer of the DRUJ. It encompasses the sheath of the extensor carpi ulnaris tendon, the ulnocarpal ligaments, the radioulnar ligaments, and the triangular fibrocartilage. The dorsal and volar radioulnar ligaments are the major stabilizers [2,4,5]. The foveal insertion of the TFCC is the most important [6] attachment for stability.
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Typically, these injuries are traumatic dislocations of the distal ulnar, either dorsal or volar. Soft tissue injuries, including TFCC injuries, causing instability are included in this group. Volar
Fig. 1. Bony anatomy of the DRUJ. Note the sigmoid notch of the distal radius and the conical shape of the ulnar head.
Secondary stabilizers There are static and dynamic stabilizers of the DRUJ [2,7,8]. Static secondary stabilizers include the joint capsule and the interosseous membrane. Dynamic stabilizers include the extensor carpi ulnaris (ECU) and pronator quadratus.
Isolated distal radioulnar joint dislocation Isolated DRUJ dislocation involves trauma to the joint that is not associated with a fracture of the radius. It is neither a Galeazzi injury nor one with injury to the distal radius articular segments of the DRUJ.
Isolated volar dislocation of the DRUJ is uncommon. Typically, the mechanism of injury is the classic fall on the outstretched arm, usually with a rotational supination force to the impact. The physical examination is notable for the absence of the typical dorsal prominence of the ulnar head and the lack of forearm rotation. Radiographs illustrate an overlap of the distal ulnar to the distal radius on the posteroanterior (PA) film (Fig. 3). A review of the literature identified 23 cases of isolated volar DRUJ dislocation since 1960 [9]. Fifteen of the 23 cases were misdiagnosed initially. If the injury was diagnosed acutely, most (9 of 11) were reduced successfully by closed reduction. Only 1 out of 12 chronic cases was treated successfully with closed reduction. Reasons to account for the irreducible dislocations included block from the TFCC [10] or the pronator quadratus [11], interposition of the extensor tendons and extensor retinaculum [12], and impaction ulnar head fracture resulting in locking on the sigmoid notch [9]. Only one chronic dislocation was treated successfully with closed reduction [13]. Most required salvage surgery (five Darrach procedures [14], three Suave Kapanji procedures [12], and one hemiresection of the ulnar head [13]). It has been suggested that a forceful closed reduction should be attempted in a chronic dislocation. This may lead to fracture if there is locked dislocation. The authors advocate the use of a CT scan of the DRUJ to exclude any impacted fracture before any attempt at a closed reduction (Fig. 4). If there is a locked dislocation with bony impaction, the authors advise open reduction of the dislocation. Dorsal
Fig. 2. Soft tissue anatomy of the DRUJ, specifically the TFCC. Note the ulnar sheath of the extensor carpi ulnaris tendon, the ulnocarpal and radiocarpal ligaments, and the triangular fibrocartilage itself. (Courtesy of Amit Gupta, MD, and Makoto Tamai, MD, Louisville, KY.)
Dorsal dislocation is more common than volar dislocation of the DRUJ. Dorsal dislocations also occur with a similar mechanism to the volar dislocation as described above. The rotational moment usually is in pronation. The physical examination usually indicates excessive prominence of the ulnar head and the similar lack of forearm rotation.
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Fig. 3. PA (A) and lateral (B) radiographs of an acute DRUJ dislocation. There is overlap of the ulnar head with the distal radius, whereas a normal joint space should be seen. Note the volar position of the ulnar head on the lateral projection.
Radiographs show findings similar to those for volar dislocations, except that the ulnar head is displaced in the dorsal direction on the lateral projection. Usually, closed reduction is successful using digital pressure over the ulnar head and supination. The dislocation may be complicated by irreducibility or ongoing instability (complex dislocation). In these cases, the patient can be managed as described below for patients with combined injuries. Underlying factors that may block reduction are similar to those described above for isolated volar dislocation.
Fig. 4. CT axial cut of a locked volar dislocation of the DRUJ, comparison with the normal contralateral wrist is provided.
Combined injury with fractured radius Combined injuries include Galeazzi injuries or distal radial fractures with DRUJ injury. A Galeazzi injury is characterized by a displaced distal radius fracture with a dislocation of the DRUJ. Usually, the diagnosis is straightforward, owing to the often dramatic appearance of the disruption of the DRUJ with the displaced radius (Fig. 5). Typically, the dislocation is dorsal, but it can occur in any direction depending on the displacement of the distal segment of the radius. Frequently, fractures of the distal radius associated with displacement result in an injury to the ulnar side of the wrist. This may involve the ulnar shaft, neck, or head fracture. More typically, there is some disruption of the soft tissue supporting structures of the DRUJ, resulting in varying degrees of instability, subluxation, or dislocation. Traditionally, DRUJ instability was believed to occur rarely in combined injuries [15–17]. Sixty percent [15] of patients with a distal radius fracture have an ulnar styloid fracture, but most do not have instability. Recent outcome reviews found that ulnar-sided wrist problems occur in 3% to 37% of distal radial fractures [18–23] and often are due to DRUJ instability. A large-sized ulnar styloid fragment (type II fractures [19]) with displacement is more likely to result in DRUJ instability [19,21,24]. Many patients with a distal radius fracture have accompanying
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Fig. 5. Galeazzi fracture-dislocation of the wrist. Preoperative initial radiographs reveal the gross displacement of the radius fracture with the dislocation of the distal radioulnar joint. Preoperative initial lateral radiograph with dorsal dislocation of the ulnar head. Postoperative radiographs indicate anatomic reduction of the radius and the DRUJ.
TFCC tears; however, they are likely to remain asymptomatic if the joint is stable [25]. Reduced outcome scores have been well documented in radial fractures complicated by instability [23,26–28]. If the clinician has an awareness of the possibility of these associated DRUJ injuries, clinical and radiological testing can be directed toward recognizing and effectively treating these injuries and improving their outcome. The instability of the DRUJ in association with radial fractures can be addressed acutely or chronically. Acute injury Early treatment of acute injury gives rise to better results than does surgical management of chronic instability [18,21,29]. An algorithm is described for the management of acute DRUJ instability (Fig. 6) associated with radial fracture. This is based on a series of difficult cases [30] that was managed by the senior author and a review of the literature. The risk for DRUJ instability can be assessed according to the mechanism of injury (eg, highenergy trauma with rotational component) and initial radiographs. Radiological indicators of potential DRUJ instability include (1) an ulnar styloid fracture involving the base with more than 2 mm displacement [18,21,31], (2) an irreducible dislocation of the DRUJ, (3) fractures
involving the sigmoid notch of the radius, (4) a wide displacement of the DRUJ, and (5) radial shortening. In the operating room, the initial goal is anatomic reduction of the radius. Following reduction of the radius, the DRUJ can be assessed for stability in different positions of forearm rotation using the piano key sign [32]. The presence of this sign can be subtle and comparison to the contralateral DRUJ may be required. If the joint is stable, no further operative intervention is required, whereas any ongoing instability must be addressed. If instability is detected, the quality of the radius fracture reduction should be reassessed to ensure restoration of the anatomy. If the reduction in nonanatomic, it must be revised, and the status of the DRUJ must be reevaluated. Instability that occurs in some positions of forearm rotation may be considered for casting in a position of stability. Typically, dorsal dislocations are stable in supination, whereas the unusual volar dislocations are stable in pronation. The limb can be immobilized in the stable position with an above-elbow splint or brace for a period of 4 to 6 weeks until the soft tissue structures stabilize. Complex instability occurs when the DRUJ is irreducible or unstable in all positions. Fig. 7 illustrates the typical pathology noted with a complex injury of the DRUJ.
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ACUTE DRUJ INJURY
Anatomic Reduction of Radius then Assess DRUJ Stability
Complex DRUJ Injury
Stable DRUJ
Partially Stable DRUJ
No Immobilization Required
Hold in Position of Stability for 4-6 weeks
Unstable in All Directions
Irreducible
Open Reduction Required Ulnar Styloid Fracture?
Large Displaced Ulnar Styloid
No Ulnar Styloid Fracture
Open Reduction and Internal Fixation
Repair of TFCC with transfixion pinning of reduced DRUJ for 4-6 weeks
Fig. 6. Algorithm for the management of acute injuries of the DRUJ.
Irreducible distal radioulnar joint An irreducible DRUJ has a block to reduction. This is characterized by soft tissue, or less often, bone interposition within the joint. Complete joint reduction may be blocked by (1) the ulnar head incarceration through a rent in the capsule of the DRUJ, (2) tendons, such as the ECU or flexor carpi ulnaris, (3) a bone fragment from the ulnar or sigmoid notch of the radius. If the joint cannot be reduced, an arthrotomy is performed, and the offending obstacle to reduction is removed. The approach is dictated by
the pattern of displacement of the dislocation. Often, the simplest approach is to expose the DRUJ by way of the ECU subsheath. This involves mobilizing the ECU with a dorsal ulnar linear incision. The skin incision is made, and the dorsal sensory branch of the ulnar nerve is identified and protected. The ECU tendon is retracted, and the subsheath is incised longitudinally. This brings the surgeon directly onto the ulnar styloid. This exposure allows reconstruction of the TFCC and the ulnar styloid, should it be indicated (Fig. 8). If the ulnar head is trapped
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Fig. 7. Typical pathology associated with a complex dislocation, showing disruption of the distal radioulnar joint ligaments, a portion of the interosseous membrane, the floor of the ECU tendon sheath, and an avulsion fracture of the ulnar styloid process. (From Cheng SL, Axelrod TS. Management of complex dislocations of the distal radioulnar joint. Clin Orthop Relat Res 1997;341:186; with permission.)
within the volar capsule, a volar exposured between the long flexors and the ulnar neurovascular structuresdallows adequate visualization of the joint and capsule to perform an open reduction. Reducible but unstable distal radioulnar joint Usually, instability in all positions is associated with a large, displaced ulnar styloid fracture and is managed by way of internal fixation. Often, this also addresses the stability of the DRUJ because the TFCC is attached to the fragment (see Fig. 8) [24,33]. If the ulnar is not fractured, the TFCC is likely to have a peripheral tear. Closed treatment of an unstable DRUJ results in a high incidence of recurrent subluxation or dislocation and residual pain [34]. Surgical options in this situation include reduction of the DRUJ with ulno-radial transfixion pins [35–38], repair of the TFCC (open [18], mini-open [39], or arthroscopically [40–46]), or an external fixateur of the radius with an outrigger to the ulnar [47]. There are few studies to guide which of these techniques has the best outcome,
Fig. 8. The technique of tension band wire fixation of the ulnar styloid process. A 1.6-mm K-wire is used to fix the styloid process to the ulnar shaft, and a 22-gauge wire is passed around the ulnar collateral ligament complex and the ulnar styloid. It is then passed through a drill hole in the ulnar shaft and tied in a figure-of-eight fashion. The inset shows completed fixation with the Kwire bent over and cut short to prevent irritation of the adjacent soft tissues. (From Cheng SL, Axelrod TS. Management of complex dislocations of the distal radioulnar joint. Clin Orthop Relat Res 1997;341:187; with permission.)
with each technique having reported success in small case series. The authors favor mini-open repair of the TFCC with short-term transfixion pins in supination. The suture repair of the TFCC with a grossly unstable DRUJ dislocation is not strong enough with current techniques to hold the reduction until healing is complete. Transfixion pinning gives initial protection to the repair.
Chronic instability following fracture of the distal radius Chronic instability of the DRUJ can undergo a trial of nonoperative management, including bracing [48]. These cases can have other causes of ulnar-sided wrist pain that may mimic or coexist with DRUJ instability. These include DRUJ arthritis, ECU tendonitis, ulnar abutment, central TFCC tear, and ulnar carpal instability. These
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Finally, if repair or reconstructive procedures are unsuccessful or not indicated (eg, DRUJ degenerative changes), salvage surgery can be considered. These include Darrach [62], SauveKapandji [63], ulnar head arthroplasty, and hemiresection [64] procedures.
CHRONIC DRUJ INJURY
Degenerative Change of DRUJ?
YES
Summary
NO
Salvage procedure: eg Darrach, Sauve-Kapandji, or hemiresection.
YES Osteotomy (radius or ulna) or osteoplasty + soft tissue stabilization
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Any Bony Deformity?
A knowledge and awareness of the stabilizing factors of the DRUJ are important in managing DRUJ instability. An algorithm for management options presented here allows the clinician to make sound clinical decisions for the management of complex instability of the DRUJ in trauma.
NO
References Soft tissue stabilizing procedure
Fig. 9. Algorithm for the management of chronic posttrauma instability of the DRUJ.
conditions should be considered in the clinical and radiological assessment. If nonoperative treatment is unsuccessful, the goals of surgical treatment are to restore stability and obtain a functional painless arc of forearm rotation. To achieve this, one must identify any bony deformity or ligament injuries. An algorithm is described for the management of chronic DRUJ instability (Fig. 9). Bony abnormalities causing instability include radial or ulnar malunion or loss of the curve of the radius on the sigmoid notch. Osteotomies of the radius [49,50] or ulnar [51] or an osteoplasty of the sigmoid notch [52] can improve stability in these situations. Once the bony anatomy is restored, the soft tissue can be addressed. Late repair of the TFCC complex can be considered [53], although attenuated tissues may preclude primary repair. Reconstructive procedures can be used if there is no DRUJ arthritis and the sigmoid notch is competent. Possible reconstructions include indirect radioulnar link by way of an ulnar carpal sling or tenodesis [54–57] or reconstruction of the distal radioulnar ligaments [58,59]. These techniques were reported to give improvement in small series. Cadaveric studies, however, showed that tenodesis procedures do not restore DRUJ mechanics [60], whereas intraarticular reconstructive procedures restore stability without limitations on forearm rotation [61].
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